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PubMed2004

Airway inflammation and remodelling changes in patients with chronic cough: do they tell us about the cause of cough?

Airway mucosal changes have been reported in chronic cough. In cough variant asthma and in eosinophilic bronchitis, there is evidence of eosinophil infiltration and sub-basement membrane thickening. In non-asthmatic cough, an increase of bronchoalveolar mast cells, mucosal mononuclear cells, and epithelial shedding have been reported. In a more recent study, evidence of airway wall remodelling has been observed in both asthmatic and non-asthmatic cough, such as an increase in sub-basement membrane thickness, goblet cell area, vascularity and vessel size. Smooth muscle area was increased in non-asthmatic coughers. Heightened cough sensitivity in non-asthmatic coughers was related to the degree of goblet cell hyperplasia and epithelial shedding. Cough reflex may be heightened by increased production of growth factors that might be further enhanced by the physical effects of cough on the airways. Mast cells may participate in the cough pathophysiology through release of growth factors as well as tussive mediators. Changes in the airway wall mucosa and epithelium may be important in the pathogenesis of cough receptor sensitization.

Airway Resistance↗
PubMed2005

Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study.

PURPOSE: Cough and more generally abdominal strain determine a pelvic floor contraction which allows an increase in sphincter pressure to prevent leakage during stress. Many electrophysiological studies have demonstrated this reflex (formally cough anal reflex). We postulated that the perineal muscle contraction following cough is not a simple binary response but proportional to the intensity of the cough. MATERIALS AND METHODS: A total of 16 women (mean age 52 years) without neurological disease or stress urinary incontinence, referred for frequency and urgency without urge incontinence, underwent urodynamic investigation. Vesical pressure was compared to electromyographic activity of the anal sphincter during 4 successive coughs of different intensity, namely gentle, moderate, strong and very strong efforts. These 4 graded coughs were repeated at 0, 100, 200, 300 and 400 ml of filling during cystometry. RESULTS: All patients were able to determine a graded cough at each level of filling. In all patients and at each level of filling a strict relationship between intravesical pressure (intensity of cough) and integrated electromyographic value was demonstrated. The greater the intensity of the cough the greater the electromyographic response of the anal sphincter. There is a strict correlation between vesical pressure and integrated electromyographic value at rest at O (R2 = 0.983) or at 100 ml (R2 = 0.970), 200 (R2 = 0.918) or 300 ml (R2 = 0.960). Bladder filling does not modify the responses. CONCLUSIONS: Pelvic floor muscle contraction increases with the importance of intra-abdominal pressure generated during stress. This gradual adaptation of pelvic floor muscles is probably 1 of the main factors which contributes to stress urinary and fecal continence in women. It must be preprogrammed by the central nervous system to maintain continence during various stresses.

Adult↗
PubMed2003

Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ).

BACKGROUND: Chronic cough is a common condition which has a significant impact on quality of life. Assessment and management are hampered by the absence of well validated outcome measures. The development and validation of the Leicester Cough Questionnaire (LCQ), a self-completed health related quality of life measure of chronic cough, is presented. METHODS: Patients with chronic cough were recruited from outpatient clinics. The development of the LCQ consisted of three phases: phase 1 (item generation); phase 2 (item reduction, allocation of items to domains and validation of questionnaire); phase 3 (repeatability and responsiveness testing of final version of questionnaire). RESULTS: Phase 1: Literature review, multidisciplinary team meeting and 15 structured interviews with chronic cough patients generated 44 items (LCQ1) with a 7 point Likert response scale. Phase 2: 104 chronic cough outpatients completed the LCQ1 along with an importance rating for each item. The clinical impact factor method was used for item reduction to 19 items (LCQ2: final version). These items were divided into three domains (physical, psychological and social) following expert opinion. Internal reliability, as assessed using Cronbach's alpha coefficients, varied between 0.79 and 0.89. Concurrent validity was high when the LCQ2 (n=56) was compared with a cough visual analogue score (r=-0.72). There was a moderate relationship with response to the St George's Respiratory Questionnaire (r=-0.54) and SF36 total score (r=0.46). Phase 3: Two week repeatability (n=24) was high with intraclass correlation coefficients for domains varying between 0.88 and 0.96. Responsiveness in nine patients whose cough was successfully treated varied within domains from an effect size of 0.84 to 1.75. CONCLUSION: The LCQ is a valid, repeatable 19 item self-completed quality of life measure of chronic cough which is responsive to change. It should be a useful tool in clinical trials and longitudinal studies.

Adult↗
PubMed2003

Psychogenic cough in a schoolboy: evaluation using an ambulatory cough recorder.

Psychogenic cough occurs most commonly in patients under 18 years of age. Making the diagnosis on clinical features alone is problematic, and it is usually a diagnosis of exclusion after several negative clinical investigations. We report on the case of a 13-year-old schoolboy with a 3-month history of persistent dry cough with no other associated symptoms. Clinical examination and investigations revealed no abnormality, and empirical trials of antiasthma and antacid medications proved unsuccessful. An objective assessment of his cough frequency was made using an ambulatory cough monitor. A large number of cough episodes were recorded during the day, but during the time he was in bed there were very few episodes recorded. This suggested a diagnosis of psychogenic cough, and he underwent behavior modification therapy under the guidance of a clinical psychologist, with good result. Objective cough monitoring may therefore improve the evaluation and management of chronic cough.

Adolescent↗
PubMed2002

Chronic cough and the cough reflex in common lung diseases.

Following the experience of asthma, characterised by the presence of bronchial hyper-responsiveness, the notion has been accepted that the chronic cough of disease occurs as a result of altered sensitivity of the afferent limb of the cough reflex. Methods for testing for the 'threshold' for eliciting the cough reflex have also been borrowed from asthma care. In the main aerosols are inhaled that contain the relevant stimulus.A number of factors influence the cough response to inhaled aerosols. The distribution of the inhaled aerosol is important as certain chemically sensitive receptors are distributed in different regions of the lungs. The larynx and central airways are important but so too are the peripheral airways. The degree of bronchodilatation is also important as airway narrowing can, itself, induce coughing in man.Asthma, oesophageal reflux and rhinitis patients experience increased coughing, that is associated with increased sensitivity to inhaled capsaicin. In syndromes of chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) increased sensitivity to coughing with capsaicin is common. This appears a specific effect of the pathogenic process of the disease. Modification of the disease process can lessen coughing and the sensitivity to capsaicin.

Asthma↗
PubMed2004

What has dry cough in common with pruritus? Treatment of dry cough with paroxetine.

Distressing persistent dry cough is commonly the consequence of sensitization of the cough reflex. A slight and transient peripheral nociceptive impulse, such as bronchitis, may be perpetuated for weeks because of sensitization of the cough reflex. Cough usually can be inhibited by opioids, but some types of cough can be out of opioid control or even be induced by opioids. We describe here a series of 5 patients with dry cough that did not respond to codeine. Because two of these patients also suffered with pruritus, paroxetine was tried. In all patients, cough ceased within hours to days. The only observed adverse effect was sleepiness in the first days of therapy. Paroxetine should be investigated as antitussive in cases of opioid-resistant cough. The putative mechanism of action of paroxetine on pruritus and rough is discussed.

Adult↗
PubMed2003

Effect of acute unilateral middle cerebral artery infarcts on voluntary cough and the laryngeal cough reflex.

OBJECTIVE: The purpose of this study was to assess the effect of acute unilateral middle cerebral artery (MCA) infarctions in right-handed subjects on their ability to elicit voluntary cough (VC), and separately to assess the laryngeal cough reflex using the reflex cough test. DESIGN: This prospective, clinical study involved 30 right-handed, alert subjects with no previous history of stroke or asthma and with an infarction of the MCA distribution as seen on computed tomographic or magnetic resonance images. Subjects could follow verbal commands. A total of 16 subjects had right MCA infarcts and 14 had left MCA infarcts. VC responses and reflex cough test results were compared with the side of the infarct. The reflex cough test used nebulized tartaric acid. RESULTS: The laryngeal cough reflex was normal in all 30 subjects, irrespective of side of MCA infarction, and none developed aspiration pneumonia. Eleven of the 14 subjects who had a left MCA infarct had an abnormal VC (78.6%) and showed cough apraxia. All 16 subjects with right infarcts produced a VC. Subjects with left infarcts were more likely to have an abnormal VC than those subjects with right lesions (P < 0.001). CONCLUSIONS: VC is of limited use in screening subjects for aspiration pneumonia risk. A normal laryngeal cough reflex indicated a neurologically protected airway.

Cough↗
PubMed2005

Change in bronchial responsiveness and cough reflex sensitivity in patients with cough variant asthma: effect of inhaled corticosteroids.

BACKGROUND: Cough variant asthma (CVA) is a cause of chronic cough and a precursor of typical asthma. We retrospectively examined the longitudinal change in bronchial responsiveness and cough reflex sensitivity in CVA patients with respect to the effect of long-term inhaled corticosteroids (ICS). METHODS: Provocative concentration of methacholine causing a 20% fall in forced expiratory volume in one second (PC20-FEV1) and provocative concentration of capsaicin eliciting 5 or more coughs (C5) were measured before treatment and during a follow up period following relief of cough (median; 2.0 (range; 0.5 to 8.0) years after the initial visit) in a total of 20 patients with CVA (7 males and 13 females, mean +/- SD age of 49.9 +/- 12.9 years). RESULTS: Three of 8 patients not taking long-term ICS developed typical asthma compared to none of 12 patients taking ICS (p = 0.0171). PC20-FEV1 significantly (p < 0.0001) increased from 1.80 (GSEM, 1.35) to 10.7 (GSEM, 1.63) mg/ml in patients taking ICS but did not change in patients not taking ICS [2.10 (GSEM, 1.47) compared to 2.13 (GSEM, 1.52) mg/ml]. Cough threshold did not change in patients whether taking or not taking ICS. CONCLUSION: Long-term ICS reduces bronchial hyperresponsiveness in CVA as recognized in typical asthma. Cough reflex sensitivity is not involved in the mechanism of cough in CVA.

Journal Article↗
PubMed1984

Influence of cerebral cortex stimulation upon cough-like spasmodic expiratory response (SER) and cough in the cat.

In 27 pentobarbitalized cats, the influence of electrical stimulation of the cerebral cortex upon the spasmodic expiratory response (SER) was studied and compared with cortical influences on coughing induced by stimulation of the superior laryngeal nerve (sup. laryngeal N.). This cortical influence was evoked by electrical stimulation of the cortical nucleus of amygdala (Aco), and was very similar to coughing accompanying changes in emotional behavior and was depressed more effectively by psychotropics than by centrally acting antitussives like codeine. When anterior cingulate gyrus (ant. cingulate G.) or orbital gyrus (orbital G.) were stimulated simultaneously with Aco or sup. laryngeal N., weak stimulation was sufficient to inhibit SER, while stronger stimuli were needed for the suppression of cough. If the same cortical regions were stimulated after initiation of SER or cough, SER was markedly suppressed but cough little affected. Production of SER was facilitated by simultaneous stimulation of the piriform lobe (piriform L.) or olfactory tract (olfactory T.), whereas cough production was facilitated by simultaneous stimulation of the suprasylvian gyrus. These results suggest that SER and coughing are differently controlled by the cerebral cortex, and that SER is modulated by the limbic cortex, in particular, by ant. cingulate G., orbital G. and piriform L. The mechanism of modulation for SER is discussed.

Amygdala↗
PubMed2006

Sensory neuropathic cough: a common and treatable cause of chronic cough.

OBJECTIVE: To describe our experience with chronic sensory neuropathic cough and its response to amitriptyline in a first group of patients. STUDY DESIGN AND SETTING: A prospective cohort of patients is described in detail. Each was referred to an academic laryngological practice after extensive prior negative workup for cough and failure to respond to various treatments. Each of these patients was treated with amitriptyline and asked to report the effect on the cough at fixed intervals by means of telephone interviews. RESULTS: A first cohort of 12 consecutive patients with a chronic, nonproductive cough that lasted between 2 months and 20 years, with no (formerly) discernible cause is described. Purely clinical criteria of inclusion and exclusion are proposed. All patients had at least 40% reduction of self-reported symptoms, with most describing between 75% to 100% short-term relief. CONCLUSION: Sensory neuropathic cough can be diagnosed clinically in patients with chronic idiopathic cough. A trial of amitriptyline 10 mg or of other anti-neuralgia type medications may be helpful. Longer term and controlled trials are warranted to validate this entity and prove efficacy of neurologic medication in chronic sensory neuropathic cough. EBM RATING: C-4.

Adrenergic Uptake Inhibitors↗
PubMed2002

Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults.

OBJECTIVES: To determine whether over the counter cough medicines are effective for acute cough in adults. DESIGN: Systematic review of randomised controlled trials. DATA SOURCES: Search of the Cochrane Acute Respiratory Infections Group specialised register, Cochrane Controlled Trials Register, Medline, Embase, and the UK Department of Health National Research Register in all languages. INCLUDED STUDIES: All randomised controlled trials that compared oral over the counter cough preparations with placebo in adults with acute cough due to upper respiratory tract infection in ambulatory settings and that had cough symptoms as an outcome. RESULTS: 15 trials involving 2166 participants met all the inclusion criteria. Antihistamines seemed to be no better than placebo. There was conflicting evidence on the effectiveness of antitussives, expectorants, antihistamine-decongestant combinations, and other drug combinations compared with placebo. CONCLUSION: Over the counter cough medicines for acute cough cannot be recommended because there is no good evidence for their effectiveness. Even when trials had significant results, the effect sizes were small and of doubtful clinical relevance. Because of the small number of trials in each category, the results have to be interpreted cautiously.

Acute Disease↗
PubMed2004

Cough plate versus cough swab in patients with cystic fibrosis; a pilot study.

BACKGROUND: Accurate identification of lower respiratory tract pathogens is important in the management of cystic fibrosis patients. AIM: To evaluate the cough plate as an alternative method of obtaining respiratory samples for microbiological culture. METHODS AND RESULTS: Using sputum culture as the "gold standard", the cough plate method identified significantly more positive cases than either dry or moistened cough swabs. Of 20 patients who had a positive sputum culture, 16 had a positive culture on cough plate compared to seven positive cultures each on moistened swab and on dry swab respectively. CONCLUSIONS: In this study cough plates were more sensitive than cough swabs in isolating respiratory pathogens in sputum producers. As patients prefer it, the cough plate merits further evaluation, particularly in non-sputum producers.

Adolescent↗
PubMed2005

A rare cause of specific cough in a child: the importance of following-up children with chronic cough.

For many years, the term 'specific cough' has been used as a clinical cough descriptor in children to signify the likelihood of an underlying disease causing the cough. In this case study, we describe a child with specific cough caused by a rare carcinoma, a mucoepidermoid carcinoma of the bronchus. The cough only totally resolved after the primary cause was successfully treated. This report highlights the importance of following up children with cough, especially those with specific cough.

Journal Article↗
PubMed2005

Cough symptoms in children aged 5-14 years in Sydney, Australia: non-specific cough or unrecognized pertussis?

OBJECTIVE: The aim of this study was to estimate the community prevalence of coughing symptoms, consistent with surveillance definitions for pertussis, and doctor-diagnosed pertussis in children aged 5-14 years. METHODOLOGY: A telephone survey of a cross-sectional community sample of parents regarding their child's cough symptoms in the previous 12 months was undertaken in a representative Australian urban region. RESULTS: In 2020 interviews, parents reported that 22% of children had a cough lasting 2 weeks or longer in the preceding 12 months, and 14% (283) had additional symptoms meeting the Centers for Disease Control (CDC) case definition for pertussis. A cough meeting the case definition was significantly more commonly reported by parents of children aged 5-9 years (17%; P < 0.001) but reported exposure to diagnosed pertussis in such cases was significantly more common in children aged 10-14 years (4.3%; odds ratio 12.8; P < 0.01). Parents of 90% of children meeting the CDC case definition sought medical advice. A diagnosis of pertussis was reported in only 1.2% of cases, which extrapolates to an annual incidence of doctor-diagnosed pertussis of 347/100,000 (95% confidence interval, 140-714 per 100,000). This contrasts with 29/100,000 notified cases in the same age group, time period and geographic area. CONCLUSION: Cough episodes meeting a clinical case definition for pertussis commonly used in surveillance are reported by a high proportion of carers of school-aged children in Australia. The majority of children who met the CDC and Australian case definitions for pertussis and sought medical attention were not identified as potentially having pertussis, suggesting underdiagnosis of pertussis. Even if less than half of this is true pertussis, the potential impact in terms of transmission of pertussis in the community is likely to be high. The reported incidence of doctor-diagnosed disease estimated from this survey was at least five and up to 20 times the official notification rate. More work needs to be done in raising awareness among medical practitioners of pertussis as a differential diagnosis in older children and adolescents with cough.

Adolescent↗
PubMed2005

A new tool to assess and monitor the burden of chronic cough on quality of life: Chronic Cough Impact Questionnaire.

INTRODUCTION: Chronic cough, one of the most frequent causes for a patient to consult a medical practitioner, limits the course of normal activities in everyday life of the patient affected (work, physical activities, social relations, night sleep). By now, there are few validated questionnaires for the evaluation of the impact of this symptom in the patient's quality of life (QoL). For this reason, we created a new questionnaire for the assessment of QoL in patients affected by chronic cough (Chronic Cough Impact Questionnaire, CCIQ). MATERIALS AND METHODS: In the development procedure of CCIQ an initial questionnaire of 40 items was compiled and given to a first pool of 170 patients, each coming to our attention because of chronic cough; then the 25 most significant items were detected and converted into questions evaluating the answers on a Likert scale of five steps. Consequently, this final questionnaire underwent a validation procedure to assess its construct validity, internal consistency, reliability, and responsiveness. 95 patients (44.2% F, 55.8% M) were evaluated (age 53.69 +/- 11.7 years). RESULTS: Following a statistical analysis, CCIQ showed a four-dimensional structure and good levels of internal consistency for the extracted factors: sleep/concentration (79.98), relationship (86.98), daily life impact (69.04), and mood (65.41). In stable conditions CCIQ showed a good reliability, ranged between 0.67 and 0.88. Responsiveness to clinical changes was accomplished. DISCUSSION: These results provide evidence that CCIQ has specificity enough for being a valid tool for detecting the relative burden of cough on subjective well-being, and for obtaining a global evaluation both of chronic cough impact and of treatments for it, taking into account the patient's point of view. The CCIQ was easily and quickly filled in by the patients while waiting, and it was accepted by the patients.

Adult↗
PubMed1999

The incidence of cough: a comparison of lisinopril, placebo and telmisartan, a novel angiotensin II antagonist. Telmisartan Cough Study Group.

Dry cough is a troublesome side-effect associated with certain antihypertensive agents that act by modulating aspects of the renin-angiotensin-aldosterone system. The incidence of dry cough associated with two of these therapies, the novel All receptor antagonist telmisartan and the ACE inhibitor lisinopril, was assessed in a multicentre, randomised, parallel-group, double-blind, placebo-controlled, 8-week study of 88 patients with mild to moderate hypertension who previously demonstrated ACE inhibitor-related cough. Patients received either telmisartan 80 mg, lisinopril 20 mg, or placebo once daily. Cough incidence, measured at each visit by a self-administered symptom assessment questionnaire, was significantly higher with lisinopril (60%) than with telmisartan (15.6%) or placebo (9.7%). A visual analogue scale demonstrated a similar trend for cough frequency. Thus the incidence of cough with telmisartan 80 mg is significantly less than that seen with lisinopril 20 mg and is comparable to placebo.

Adolescent↗